Der obere Atemweg bei OSA-Patienten ist auch im Wachzustand pathologisch

Zusammenfassung

Die obstruktive Schlafapnoe (OSA) ist charakterisiert durch eine partielle bzw. komplette Obstruktion des pharyngealen Atemwegs. Prinzipiell kann man anatomische von nicht-anatomischen Faktoren unterscheiden. Alter und Adipositas stellen die Hauptrisikofaktoren für OSA dar, dennoch sind etwa 50% der Patienten nicht adipös. Im höheren Alter (>60 Jahre) nimmt der Stellenwert der Adipositas ab, es werden vermehrt normgewichtige Patienten mit OSA gefunden. Durch Effekte der chronisch intermittierenden Hypoxämie, der Low-grade-Inflammation, des erhöhten Sympathikotonus sowie der mechanischen Beanspruchung kommt es zu einer Muskelfasertransformation im oberen Atemweg mit verminderter Muskelmasse und -kraft. Seltener auftretende nicht-anatomische Faktoren sind ein reduzierter muskulärer Tonus, eine erhöhte Arousalschwelle sowie eine veränderte Sensibilität der Chemorezeptoren auf CO₂.

Abstract

Obstructive sleep apnea (OSA) is characterized by partial or complete obstruction of the pharyngeal airway. Anatomical factors can be distinguished from non-anatomical factors. Age and obesity are the main risk factors for OSA; however, approximately 50% of patients are not obese. In older patients (>60 years), the importance of obesity decreases. There is an increased prevalence of OSA among patients with normal weight. The effects of chronic intermittent hypoxemia, low-grade inflammation, increased sympathetic tone and mechanical stress contribute to a transformation of muscle fibers in the upper airway, resulting in reduced muscle mass and strength. Less frequently encountered non-anatomical factors include decreased muscle tone, increased arousal threshold, and altered sensitivity of CO₂ chemoreceptors.

Schlüsselwörter

obstruktive Schlafapnoe - pharyngealer Atemweg - chronisch intermittierende Hypoxie - Atemwegsmuskulatur - Chemorezeption

Keywords

obstructive sleep apnea - pharyngeal airway - chronic intermittent hypoxia - airway muscles - chemoreception

Publication History

Received: 26 May 2023

Accepted after revision: 10 July 2023

Article published online:
30 August 2023

• Literatur

• 1 Edwards BA, Wellman A, Sands SA. et al. Obstructive Sleep Apnea in Older Adults is a Distinctly Different Physiological Phenotype. Sleep 2014; 37: 1227-1236 DOI: 10.5665/sleep.3844. (PMID: 25061251)
• 2 Genta PR, Schorr F, Eckert DJ. et al. Upper airway collapsibility is associated with obesity and hyoid position. Sleep 2014; 37: 1673-1678
• 3 Genta PR, Schorr F, Edwards BA. et al. Discriminating the severity of pharyngeal collapsibility in men using anthropometric and polysomnographic indices. J Clin Sleep Med 2020; 16: 1531-1537 DOI: 10.5664/jcsm.8600. (PMID: 32441245)
• 4 Malhotra A, Huang Y, Fogel R. et al. Age influences on pharyngeal anatomy and physiology: the predisposition to pharyngeal collapse. Am J Med 2006; 119: 72.e9-72.e14
• 5 Kirkness JP, Schwartz AR, Schneider H. et al. Contribution of male sex, and obesity to mechanical instability of the upper airway during sleep. J Appl Physiol 2008; 104: 1618-1624
• 6 Oliveira MC, Tufik S, Haddad FL. Systematic Evaluation of the Upper Airway in a Sample Population: Factors Associated with Obstructive Sleep Apnea Syndrome. Otolaryngol Head Neck Surg 2015; 153: 663-670
• 7 Li Y, Lin N, Ye J. et al. Upper Airway Fat Tissue Distribution in Subjects With Obstructive Sleep Apnea and Its Effect on Retropalatal Mechanical Loads. Respir Care 2012; 57: 1098-1105
• 8 Schwab RJ, Kim C, Bagchi S. et al. Understanding the Anatomic Basis for Obstructive Sleep Apnea syndrome in Adolescents. Am J Respir Crit Care Med 2015; 191: 1295-1309 DOI: 10.1164/rccm.201501-0169OC. (PMID: 25835282)
• 9 Osman AM, Carter SG, Carberry JC. et al. Obstructive sleep apnea: current perspectives. Nature and Science of Sleep 2018; 10: 21-34 DOI: 10.2147/NSS.S124657. (PMID: 29416383)
• 10 Zinchuk A, Gentry M, Concato J. et al. Phenotypes in obstructive sleep apnea: a definition, examples and evolution of approaches. Sleep Med Rev 2017; 35: 113-123 DOI: 10.1016/j.smrv.2016.10.002. (PMID: 27815038)
• 11 Petrof BJ, Pack AI, Kelly AM. et al. Pharyngeal myopathy of loaded upper airways in dogs with sleep apnea. J Appl Physiol 1994; 76: 1746-1752
• 12 Schäfer T. Pathophysiologie der Atmung unter besonderer Berücksichtigung schlafbezogener Atmungstörungen. Laryngo-Rhino-Otol 2006; 85: 1-10
• 13 Kimoff J, Sforza E, Champagne V. et al. Upper airway sensation in snoring and obstructive sleep apnea. Am J of Respir Crit Care Med 2001; 164: 250-255 DOI: 10.1164/ajrccm.164.2.2010012. (PMID: 11463596)
• 14 D’Angelo GF, Mello AA, Schorr F. et al. Muscle and visceral fat infiltration: A potential mechanism to explain the worsening of obstructive sleep apnea with age. Sleep Medicine 2023; 104: 42-48
• 15 Wu R, Delahunt E, Ditroilo M. et al. Effects of age and sex on neuromuscular-mechanical determinants of muscle strength. AGE 2016; 38: 57 DOI: 10.1007/s11357-016-9921-2. (PMID: 27189591)
• 16 Piovezan RD, Yu S, Hirotsu C. et al. Associations of indicators of sleep impairment and disorders with low muscle strength in middle-aged and older adults: The Hypno Laus cohort study. Maturitas 2022; 164: 52-59
• 17 Oliven R, Cohen G, Dotan Y. et al. Alteration in upper airway dilator muscle coactivation during sleep: comparison of patients with obstructive sleep aonea and healthy subjects. J Appl Physiol 2018; 124: 421-429
• 18 Narici MV, Mafulli N. Sarcopenia: characteristics, mechanisms and functional significance. British Medical Bulletin 2010; 95: 139-159
• 19 Bixler Eo, Vgontzas AN, Lin HM. et al. Prevalence of Sleep-disordered Breathing in Women. Effects of Gender. Am J Respir Crit Care Med 2001; 163: 608-613 DOI: 10.1164/ajrccm.163.3.9911064. (PMID: 11254512)
• 20 Campos-Rodriguez F, Queipo-Corona C, Carmona-Bernal C. et al. Continuous Positive Airway Pressure Improves Quality of Life in Women with Obstructive Sleep Apnea. Am J Respir Crit Care Med 2016; 194: 1286-1294
• 21 Silva Dantas DA, Mauad T. et al. The Extracellular Matrix of the Lateral Pharyngeal Wall in Obstructice Sleep Apnea. Sleep 2012; 35: 483-490
• 22 Boyd JH, Petrof BJ, Qutayba H. et al. Upper Airway Muscle Inflammation and Denervation Changes in Obstructive Sleep Apnea. Am J Respir Crit Care Med 2004; 170: 541-546
• 23 Schiaffino S. Fibre types in skeletal muscle: a personal account. Acta physiologica 2010; 199: 451-463 DOI: 10.1111/j.1748-1716.2010.02130.x. (PMID: 20353491)
• 24 Schiaffino S, Reggiani C. Fiber types in mammalian skeletal muscles. Physiological Reviews 2011; 91: 1447-1531 DOI: 10.1152/physrev.00031.2010. (PMID: 22013216)
• 25 Erturk N, Celik A, Kutukcu-Calik E. High- and low-intensity expiratory musle strength training in patients with severe obstructive sleep apnea syndrome using non-invasive mechanical ventilation: A double-blinded, randomized controlled trial. Heart and Lung 2023; 61: 29-35
• 26 Erturk N, Kutukcu-Calik E, Arikan H. et al. The effectiveness of oropharyngeal exercises compared to inspiratory muscle training in obstructive sleep apnea: A randomized controlled trial. Heart and Lung 2020; 49: 940-948
• 27 Sousa AS, Pereira da Rocha A, Brandaro Tavares DR. et al. Respiratory muscle training for obstructive sleep apnea: Systematic review and meta-analysis. J Sleep Res 2023; e13941: 1-27
• 28 Pae EK, Wu J, Nguyen D. et al. Geniohyoid muscle properties and myosin heavy chain composition are altered after short-term intermittent hypoxic exposure. J Appl Physiol 2005; 98: 889-894 DOI: 10.1152/japplphysiol.00978.2004. (PMID: 15557011)
• 29 Kimoff RJ, Hamid Q, Divangahi M. et al. Increased upper airway cytokines and oxidative stress in severe obstructive sleep apnoea. Eur Respir J 2011; 38: 89-97 DOI: 10.1183/09031936.00048610. (PMID: 20847078)
• 30 Sauleda J, Garcia-Palmer FJ, Tarraga S. et al. Skeletal muscle changes in patients with obstructive sleep apnoea. Respiratory Medicine 2003; 97: 804-810
• 31 Series FJ, Simoneau SA, St Pierre S. et al. Characteristics in the genioglossus and musculus uvulae in sleep apnea hypopnea syndrome and in snorers. Am J Respir Crit Care Med 1996; 153: 1870-1874
• 32 Carrera M, Barbe F, Sauleda J. et al. Patients with obstructive sleep apnea exhibit genioglossus dysfunction that is normalized after treatment with CPAP. Am J Respir Crit Care Med 1999; 159: 1960-1966
• 33 Fassbender P, Herbstreit F, Eikermann M. et al. Obstruktive Schlafapnoe – ein perioperativer Risikofaktor. Dtsch Ärztebl Int 2016; 113: 463-469
• 34 Osman AM, Carberry JC, Burke PG. et al. Upper airway collapsibility measured using a simple wakefulness test closely relates to the pharyngeal critical closure pressure during sleep in obstructice sleep apnea. Sleep J 2019; 42: 1-10
• 35 Hirata RP, Schorr F, Kayamori F. et al. Upper Airwa Collapsibility Assessed by Negative Expiratory Pressure while Awake is Associated with Upper Airway Anatomy. J Clin Sleep Med 2016; 12: 1339-1346